ECG Topic - Right Ventricular Hypertrophy (RVH)

Last updated 1/26/26

Introduction

RVH reflects chronic pressure overload of the right ventricle due to pulmonary hypertension, congenital heart disease, or chronic lung disease. ECG findings are specific but often insensitive — they are most valuable when interpreted with axis, waveform progression, and clinical context.

Electrophysiology

In a normal heart, left ventricular mass dominates ventricular depolarization. The net QRS vector points leftward and posterior, which is why V1 is usually negative and the R wave gradually increases as you move toward V6 (left). When the right ventricle enlarges, it contributes a new, stronger depolarization vector directed anteriorly and to the right. This “extra” vector shifts the overall QRS force toward V1 and V2 (right)

Adapted from Tomas Garcia’s 12 Lead ECG - Art of Interpretation

On the ECG, this manifests as:

• Tall R wave in V1
• R/S ratio > 1 in V1
• Deeper S waves as you move laterally
• Rightward QRS axis often accompanying the pattern

ECG Findings of RVH

ECG: RVH

RVH findings

• Right axis deviation - down in I and up in aVF
• R/S Ratio ≥ 1 in V1 and V2
• This patient had a history of RVH from mitral stenosis (note the LAE here)

Source: ECG Wave Maven

ECG: RVH

RVH findings

• Right axis deviation - down in I and up in aVF
• R/S Ratio ≥ 1 in V1
• LAE in V1 and borderline RAE in lead II

ECG: RVH with strain pattern

RVH findings

• Right axis deviation - down in I and up in aVF
• R/S Ratio ≥ 1 in V1 and V2
• RV strain patern with TW inversion in the right precordial leads (V1-V3)
• Dominant S waves in V5-V6
• Patient had a history of pulmonary HTN

Differential Diagnosis for Tall R Wave or R/S > 1 in V1

A dominant R wave or R/S > 1 in V1 does not always indicate RVH. Always run down the following differential diagnosis:

1. Right ventricular hypertrophy
2. Right Bundle Branch Block
3. Posterior wall acute myocardial infarction
4. Young thin children and adolescents
5. Hypertrophic cardiomyopathy
6. Dextrocardia or lead reversal

ECG: Posterior MI

Note that in a posterior MI the T wave is typically upright in V2 when compared to RVH with strain pattern

ECG: Right Bundle Branch Block

Note that the QRS is ≥ 120ms. In RVH, the QRS should not be wide (unless both diagnoses occur simulatenously)

ECG: Dextrocardia

This almost looks identifical to typical RVH pattern. The R sided leads have prominant R waves (V1-V3, III, aVR) with R axis

Key Points

• RVH is a vector problem, not a conduction problem: increased right ventricular mass shifts the QRS anteriorly and rightward.
• The hallmark pattern is right axis deviation with a dominant R wave (R/S ≥ 1) in V1 and deep S waves in V5–V6.
• RV strain (T wave inversion in V1–V3) suggests pressure overload, often from pulmonary hypertension or acute-on-chronic RV failure.
• A tall R in V1 is not specific - run through your differential diagnosis
• ECG findings are specific but insensitive: absence of RVH criteria does not exclude clinically significant RV pressure or volume overload.

References

• Chou B. Electrocardiography in Clinical Practice, 6th ed
• Garcia TB. 12-Lead ECG: The Art of Interpretation
• Brady WJ. Critical Decisions in Emergency & Acute Care ECG
• LITFL ECG Library — Right Ventricular Hypertrophy
• Mattu A. ECGs for the Emergency Physician, Vols 1–2
• The ECG – Davila

This post is for education and not medical advice.